You are at the local mall and you see a patient who appears to be homeless by his physical appearance and you witness the person “walk 50 feet to a table sit down, and after 5 seconds he gets up and walks to a tree and urinates on it” He repeats this action 5 times apparently oblivious to his surroundings.

You are at the local mall and you see a patient who appears to be homeless by his physical appearance and you witness the person “walk 50 feet to a table sit down, and after 5 seconds he gets up and walks to a tree and urinates on it” He repeats this action 5 times apparently oblivious to his surroundings. When the police come he ignores them as if they aren’t there. Later, you go to work and sitting in exam room 3 is the same person! Now, he is your patient, when you talk to him he has no recollection of his behavior by the mall.

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• What is your differential diagnosis?
• What tests do you order?
• An MRI comes back and there seems to be a lesion in the temporal lobe does this change your differential? The EEG also comes back with unusual excitatory activity. What is your definitive diagnosis?  In retrospect did anything bias your first differential?